Healthcare Provider Details

I. General information

NPI: 1700530425
Provider Name (Legal Business Name): GREGORY DENNIS HENSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 THIRD STREET
RODEO CA
94572-1304
US

IV. Provider business mailing address

1009 THIRD STREET
RODEO CA
94572-1304
US

V. Phone/Fax

Practice location:
  • Phone: 510-239-3182
  • Fax:
Mailing address:
  • Phone: 510-239-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: